Client Intake Form

REQUIRED - Please fill out form below.

* First name

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* Last name

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* Email

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* Phone number

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* Date of Birth

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* Social Security Number

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* Address

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* City

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* Country

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* State/Province

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* ZIP/Postal

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* New or Existing Client?

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If Existing, has any information changed? What?

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* Who referred you to us? Or how did you find us?

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* Name of Financial Planner? Or don't have one?

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* Interested in a Free Tax & Financial Review?

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* Do you have Insurance? Type: ie Life, LTC? Amount?

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* Do you have Investments? Type: IRA CD etc? Amount?

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* Approximate Net Worth? Type Retirement, House, etc

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* Approximate Debts? ie Mortgage, Auto, Credit Card?

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* Do you have a will or trust? Who is your attorney?

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* Single, Married, Separate, Head Household, Widow?

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*Spouse Name, DOB, SSN, email, cell phone #.

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*Dependents Name(s), DOB, SSN, Relationship to you.

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* Can someone claim you as a dependent? If so who?

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* Own a business? Name, type S-corp, LLC, sole prop?

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* Service(s) needed from us? ie Investment, Tax, QB?

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Bought/sold home? cryptocurrency? tips/overtime?

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Checking/Savings - Routing & Account # for Refunds

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* Drivers License/ID number(s), Exp date, St issued?

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* Credit Card #, Exp, Sec Code, Name for Payments

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* Do you meet requirements of EIC, CTC, AOTC, or HOH

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Krueger & Associates Tax & Business Advisory, Inc. | 103 N. State St. Krueger & Associates LTD. | Hampshire, IL 60140 US

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